Educational Research (ISSN: 2141-5161) Vol. 1(9) pp. 356-362 October 2010
Available online http://www.interesjournals.org/ER
Copyright ©2010 International Research Journals
Full Length Research Paper
Perception of care in Zambian women attending
community antenatal clinics
Menon, J.A*1; Musonda, V.C.T2, Glazebrook, C3
1
Department of Psychology, University of Zambia, Zambia.
Department of Psychology, University of Zambia, Zambia.
3
Professor of Health Psychology, School of Community Health Sciences, Division of Psychiatry, University of
Nottingham, UK
2
Accepted 10 September, 2010
Antenatal care focuses on health promotion to ensure a safe pregnancy and delivery, but it is a major
concern in most developing nations that many expectant mothers either have no access to these clinics
or do not avail of the facilities when they do exist. The study was conducted at the five antenatal clinics
under the Lusaka Urban District Health Medical Team. Data was collected from of 194 expectant
mothers (16-41 years), randomly sampled, at five antenatal clinics. A semi-structured interview
schedule was administered and Focus Group Discussions (FGDs) were carried out with the expectant
mothers. FDGs were also carried out with sisters-in-charge and/or the midwives at the five clinics.
Informed consent was obtained from all participants prior to the interview and FGDs. The results
obtained were subject to descriptive statistical analyses and qualitative analyses of the FGDs were also
carried out. The majority of the women reported that they were satisfied with care, with 98% agreeing
that the clinic was helpful. There was evidence of dissatisfaction with the amenities within the clinic
such as seating and toilet facilities. Although those participants who responded were very positive
about the nursing staff, a significant minority of women failed to respond to questions about the quality
of care. FGDs, suggests that embarrassment and fear tended to inhibit communication.
Key words: Antenatal care, Zambia, Satisfaction
INTRODUCTION
Pregnancy has been variously described as being a time
of joy and a time of sorrow – depending on the biopsycho-social conditions that the mother is faced with
during this time. This is also a period that finds the
expectant mother to be in a vulnerable position, with
regard to her physical and psychological health and in
developing countries; there is sometimes the added
burden to the pregnant woman of the family at large, with
regard to the availability of finances. These changes
often add new stresses to the lives of women who
already face many demands at home and at work
(Samuel, 1996). Pregnancy is a time when women's
health is placed at risk by a host of factors, in addition,
many pregnant women and their partners worry about the
health of the baby, their ability to cope with labour and
delivery, and their ability to become good parents
*Corresponding author E mail: anithamenon667@hotmail.com
(Samuel, 1996).
However, professionals providing
antenatal care can reduce that risk by monitoring
women's health regularly and offering preventive
services. Antenatal care is an important part of preventive
medicine, its objective being to maintain the mother in
health of body and mind, to anticipate difficulties and
complications of labour, to ensure the birth of a healthy
infant, and to help the mother rear the child (Clayton et
al., 1985).
When an expectant mother comes to hospital, she
often comes from a family and is influenced by the
community in which she lives. In the hospital she should
be able to get much support and comfort she would
normally receive from her spouse/significant other, or
someone close to her (Broadribb, 1973) the relationship
between expectant mother and the health worker is of
utmost importance. The health worker must be able offer
meaningful support, encouragement to the expectant
mother (Fisher, 1994).
The number of times a woman needs to be seen during
her pregnancy varies. Ideally, the first visit should be as
Menon et al. 357
early in the pregnancy as possible. Thereafter, she
should be seen every four weeks until the 30th week,
fortnightly until the 36th week, and then weekly until the
onset of labour. If complications should arise, more
frequent visits will be warranted (Clayton et al., 1985).
Many critics, however, have dubbed this traditional
approach to antenatal care a euro-centric model. Sadly,
many developing countries have adopted this approach
without adjusting the interventions to meet the needs of
their particular populations, taking into account their
available resources. The focused antenatal care
approach is a more practical model that can be efficiently
used in developing nations.
Pregnancy is also associated with various psychosocial
risks. A literature review by Reid et al. (1998) revealed 15
antenatal psychosocial risk factors associated with poor
postpartum family outcomes. These included woman
abuse,
child
abuse,
postpartum
depression,
marital/couple dysfunction and increased physical illness.
Another major concern is with regard to antenatal
depression. Substance dependency and experienced
difficulties, especially in relation to friends, partner and
own mother, are associated with antenatal depression
(Pajulo et al., 2001). However, the strongest risk factors
for postpartum depressive symptoms are reported to be
sick leave during pregnancy and a high number of visits
to the antenatal care clinic (Josefsson et al., 2002).
Antenatal care that is exclusively focused on somatic
conditions may lead to ignorance of pregnant women's
psychosocial problems, thus missing a chance for
intervention. Screening for psychosocial conditions in
pregnant women may reveal information about important
life aspects that are not detected in a standardized
antenatal care form (Forde et al., 1992). Melender (2002)
found fear and negative mood in expectant mothers, as a
result of negative stories told by others, alarming
information, diseases and child-related problems; and in
multiparas, negative experiences of previous pregnancy,
childbirth, and baby's health and care. Psychosocial
factors during pregnancy also seems to have a long term
effect, it was found that women who perceived their
social network as less supportive during pregnancy were
likely to see their one-year-old babies as being more
difficult (Adler et al.,1991). Cultural and various other
factors play a major role in a woman’s experience of
pregnancy. There is a qualitative difference in the way
pregnant women in developing nations, and their
counterparts who live in the developed nations respond
to pregnancy. These factors also play a role in their
experiences and perceived satisfaction from antenatal
clinics. In a descriptive type of study to find out the
attitude of the women towards utilization of antenatal care
facility in Peshwar et al. (2002) found that proximity to the
antenatal clinic was an important determinant of
attendance. Sultana and Ahemd (2002) in their study with
expectant Pakistani mothers also found that proximity to
an antenatal clinic played a significant role in attendance,
with only those living close to such a clinic utilizing its
facilities. But a South African study (Myer and Harrison,
2003) found that, despite the widespread availability of
free antenatal care services, most women in rural South
Africa attend their first antenatal clinic late in pregnancy
and fail to return for any follow up care, potentially
leading
to
avoidable
perinatal
and
maternal
complications. Culture is another factor that plays a role
in determining attendance. Petrou et al. (2001), in their
U.K. study found that Women of Pakistani origin made
9.1% fewer antenatal visits than women of white British
origin. Brieger et al. (1994) found that although a
functioning government maternity center in the Yoruba
community in Nigeria offered a full range of antenatal and
delivery services, most of the women did not register for
antenatal care until their sixth month of pregnancy or
later, and 65% delivered at home. Addai’s (1998) study in
Ghana revealed that the use of maternal health services
tend to be shaped mostly by level of education, place of
residence, region of residence, occupation, and religion.
There also seems to be lack of information in women on
the importance of attending antenatal clinic, a Tanzanian
study by Mlay et al. (1994) found that most of the women
did not know when in the course of pregnancy they
should start attending antenatal clinics.
Cost appears to play a pertinent role in antenatal clinic
attendance in developing nations. This is reflected in a
study carried out in Zimbabwe by Murira et al. (1997).
They note that the major problem limiting access to ANC
was lack of money to pay for the booking. Other
problems mentioned by the women were ignorance
regarding the best time to book, lack of privacy, and
insufficient staff at the clinics. Cost is a variable that is
pertinent not only in the developing nations, but also in
the developed ones. Michie et al. (1990) in their U.K.
study found that the woman’s “cost-benefit” judgement
was an important predictor of antenatal clinic attendance.
Widespread breakdowns in the Chinese village-level
primary health care network, for example, have led
village women to express a profound lack of confidence
in local health services (Wong et al. 1995). While an
Australian study found factors contributing to
dissatisfaction included long waiting times, staff seeming
rushed, and lack of continuity of caregiver (Laslett et al.,
1997).
Social support has been identified to play a major role
in antenatal clinic attendance. Many studies in western
countries have shown that persons who have a high level
of social support are likely to have better health
behaviours, including use of preventive health services,
than those who have low support. In a study by Jirojwong
et al. (1999) conducted in Hatyai, Thailand, relationships
between various measures of the 177 postpartum
women's social support and their use of antenatal clinics
were assessed. Their findings indicate that less than 10%
of the women studied identified health personnel as
providing support. The authors reason that the Thai
358 Educ. Res.
extended family by its very nature generates large
numbers of supporters.
Although, there has been only a few studies carried out
in Zambia, like in other parts of the world, antenatal clinic
attendance is recognized as an important preventive
mechanism employed to minimize potential pregnancyrelated complications. The occurrence of such problems
usually leads women to seek traditional assistance or
modern medical advice from established health
institutions. The decision to seek assistance, however, is
not only made by the expectant mother herself but also
by different parties related to the family or
neighbourhood, including village chiefs. According to the
Zambia District Health Services (ZDHC), the proportion of
women attending antenatal clinics increased during the
period 1992 – 1996. In 1996, 96.2 per cent of women
received antenatal care services. More women received
antenatal care from midwives or nurses than ever before,
while others seek the assistance of doctors, traditional
birth attendants , or traditional healers (Nsemukila et al.,
1998)
Nsemukila et al. (1998) also report that the benefits of
attending antenatal clinics were generally well perceived
from their Focus Group Discussions with Zambian men
and women. The quality of knowledge is reportedly
higher for older women, possibly due to previous
experiences. Their study also demonstrates a clear link
between antenatal clinics attendance and socioeconomic
status (as measured by women’s education, husband’s
education, and sources of drinking water). Age was
another factor that appeared to play a role in antenatal
clinic attendance. The younger (12 – 19 years) and the
older (40 – 44 years) women were less likely to attend
antenatal clinics than those falling in the age range of 25
– 29 years. Marital status also seems to play a crucial
role in determining attendance. Single and widowed
women were less likely to attend antenatal clinics than
their married counterparts.
Reasons for non-attendance have also been explored
in the Nsemukila et al. (1998) study. The authors report:
service-related reasons, which include: long distance
from the clinic, transport problems, nurses being
perceived as not being friendly and insufficient female
staff at the clinics, and client-oriented reasons, which
include: laziness or ignorance of the benefits of antenatal
care, and economic factors.
The foregoing review suggests that there are several
psychosocial risk factors that need to be considered to
ensure a safe pregnancy and delivery, and psychosocial
interventions have proven to be beneficial in providing
comprehensive antenatal care. As expectant mothers do
not fall into a homogeneous group, attitudes toward, and
perception of the effectiveness of antenatal care varies.
This is also the case when examining their subjective
experiences of antenatal clinic visits, and pregnancy as a
whole.
There clearly is a need to look at the Zambian context
closer, and examine the factors that determine antenatal
clinic attendance. The current study attempts to fill in this
void by exploring certain biological, psychological, social
and environmental factors that may help determine
whether or not an expectant mother visits an antenatal
clinic, whether she will come for a revisit, and whether
she will come to the clinic / hospital for the delivery.
The aim of this study was to explore satisfaction with care
in women attending Zambian Antenatal clinics.
METHODOLOGY
The study was conducted at the five antenatal clinics under the
Lusaka Urban District Health Medical Team (LUDHMT). The clinics
were selected in consultation with the LUDHMT and included clinics
in low density and high-density areas in Lusaka.
Sample
Data was collected from of 194 expectant mothers at the five
antenatal clinics in Lusaka. The criteria for inclusion were expectant
mothers in the age group of 16- 41 years who were willing to be
interviewed. Information was also collected from the sisters- incharge and the midwives at the clinics.
Study Design
This is a descriptive cross sectional study conducted in a
developing country.
Semi-structured interviews were conducted with the expectant
mothers at the clinics. Focus group discussions were also carried
out with a small group of expectant mothers, sisters-in-charge and
the midwives at the five clinics.
Instrument
A semi-structured interview schedule was used to collect the data
from the expectant mothers, and discussion guides were used for
focus group with expectant mothers and midwives. The interview
schedule was piloted with expectant mothers in one of the clinics
and appropriate changes were made.
Procedure
An appointment was made at each clinic and a convenient time for
the interviews was agreed in consultation with the sisters-in-charge
of the antenatal clinic.
The expectant mothers who were at the clinic waiting for their
routine antenatal check up were randomly requested to be
interviewed. Assurance about confidentiality was maintained at all
times. The participants were also informed that there were no
consequence for failing to participate, and that they were free to
withdraw at anytime.
The personal data of the participants were obtained from their
clinic registration cards.
The expectant mothers were individually interviewed in the
privacy of a cubicle, and the interview lasted for about ten minutes.
Guidelines for the focus group discussions (FGDs) with the
Menon et al. 359
expectant mothers and midwives were drawn up from the
preliminary data collected from the interviews. A series of FGDs
were held with the expectant mothers at the five clinics. To recruit
participants for the focus group with midwives and sisters-in-charge
of the antenatal clinics, invitations were sent out to nine LUDHMT
Centres in the city, and to the Head Office. Each centre was
requested to nominate two participants for the FGDs. The
expectant mothers were invited to take part in the FGDs after they
had completed their routine antenatal check up. Nineteen
participants were nominated from the respective clinics. The
participants were randomly divided into two groups and FGDs were
held with both the groups. The guidelines were used to stimulate
discussions .The FGDs were tape recorded after obtaining informed
consent from the participants. Each FGD lasted for about ninety
minutes.
RESULTS
A total of 194 women took part in the study with an age
range of 16 to 41 years. The mean age of the sample
was 24.5 (SD 2.8) and for 74 women (38%) this was their
first pregnancy. Family size varied from 1 child (27.8%)
to 5 children (3.1%). The women had a median of 9 years
schooling (inter quartile range 7-11 years).
The majority of the women reported that they were
satisfied with care with 98% agreeing that the clinic was
helpful.
The physical aspects of the clinic were
considered to be satisfactory, 55% of women reported
being able to find a seat and 43% reported that the toilet
facilities were satisfactory. Ninety nine percent agreed
that they would come for future appointments. Reported
satisfaction with nursing care and information provision
was also high but a higher proportion of women failed to
respond to these questions (Table 1).
Results from Focus group discussions
Focus groups were held in 5 clinics with between 8 and 9
women in each group. The facilitator worked to a
protocol formatted earlier. For the current report the
transcripts were explored for evidence that women
attending the clinics were able to discuss their concerns
and that they were satisfied with the provision of care.
Themes that were examined for this report were about
feelings towards the nursing staff in the clinic and barriers
to communication.
There was evidence that women were reluctant to share
concerns about pregnancy and birth with the clinic staff.
For example, pregnant women said, “Even if I had other
concerns bothering me, I wouldn’t be able to continue
and tell such a nurse. You find that people go back home
without ever telling the nurse the kind of problems or
concerns they have. That’s the end of it.” And this
reluctance may reflect fear of how questions might be
received.
Although several participants in the focus groups
acknowledged that many nurses were kind but some
experienced harsh treatment from some nurses. This
seemed to colour the view of the process of care leaving
women feeling vulnerable. According to one of the
participants,
“Sometimes when we come to the clinic we find goodhearted nurses; but others are rough even the way they
examine you is painful. (laughter from group) If you
complain about that they throw away your file (antenatal
book). Yes they are really rough in the way they examine
us, if you complain they will throw away your file and start
attending to the next person in the queue”. Thus it can be
said that there probably existed a feeling among the
participants that it was the responsibility of the patient to
avoid upsetting nursing staff and therefore not risking
poor care.
There was a prevailing feeling that although some
nursing staff were kind, the prevailing impression was
that nurses were likely to be rude and outspoken and that
this caused women to be wary of asking questions or
seeking advice. This was one of the responses “Okay,
speaking for myself I would say we find nurses of
different personalities here. Some are very rude to us.
You could have a question, which you ask them hoping to
get an answer but they come back to you with a very
rude answer that makes you feel bad. Sometimes you
feel embarrassed in front of other people. As I said
earlier, some are good, they make you feel welcome and
you relax in their presence. You feel they are really
helping you, as nurses should. You feel satisfied with the
service”.
Inequality in the power relationship and the perception
of the volatility of the nursing staff clearly impact on the
communication process between staff and patients. This
was seen in many of the responses. For example,
according to one of the participants, “To be honest with
you one wouldn’t even have the guts to talk to the nurses
about that. You wouldn’t dare do that. It would be a very
hard thing to do. You wouldn’t want to risk their reaction
to such a complaint” and another said, “ Then at other
th
times, like last time I came on the 17 and they told me
that I should come to the clinic if I didn’t feel well. So
going by their advice, I came when I had stomach pains
but they shouted at me”. There was also evidence that
patients did not feel confident in disclosing information to
the nurse. This may be reflecting in this response: “You
know, you know we differ. I don’t know why we hide
certain things from them. Sometimes we feel shy to tell
the nurse or the doctor the truth”.
The nature of the relationship between the nurses and
their patients means that opportunities for health
promotion are lost. It may also mean that at times such
fear may put the health of the pregnant woman at risk.
“Even when you are having pains, you just go back home
without telling them about it because you are scared of
being shouted at” was the concern of a participant.
In one of the clinics, the women seemed rather more
satisfied with the nurses’ care, perceiving them to be very
competent .This was evident from some of their
360
Educ. Res.
Table 1. Satisfaction with care
Question
The process was simple
Administrative staff members were
helpful?
The waiting room was pleasant
I was able to find a seat
The toilet facilities were good?
I found the nurses pleasant
I found nurses helpful
I found clinic useful
The nurse gave me information
I will come for future appointments
I will come to the hospital to
deliver
Agree
185 (95%)
183 (94%)
173 (89%)
107 (55%)
82 (43%)
170 (88%)
173 (89%)
190 (98%)
175 (90%)
192 (99%)
191 (98.5)
Don’t know / Disagree
8 (4%)
7 (4%)
21 (11%)
79 (41%)
108 (57%)
8 (4%)
3 (2%)
0 (0%)
8 (4%)
0 (0%)
2 (1%)
Did not respond
1 (0.5%)
4 (2%)
0 (0%)
8 (4%)
4 (2%)
16 (8%)
18 (9%)
4 (2%)
11 (6%)
2 (1%)
1 (0.5%)
The mean time that the women reported waiting was 3.6 hours with a range of 1 to 6 hours. Despite the lengthy waiting
time women appeared to committed to clinic attendance. Of the 119 women with children, only 4 (3.4%) had not attended
in their previous pregnancy. The main reason women reported attending was to check on their health (42%) though only
14 (7.2%) considered that they had health problems.
responses such as, “What I can say is that they welcome
us very well, they examine us very well and we go back
home very well satisfied with their service”; “ So, I am
happy because the antenatal examinations are done in a
friendly atmosphere. They receive and treat us very well
here”; “The service is good. They help us very well
because when we come here and tell the nurses that you
are not feeling well they attend to you very well. They
give us medicine and tell us about how to take care of
ourselves”. The nurses here were perceived as being
interested in the health of the women and that the
patients feel happy to discuss their health concerns. It
may be that the nurses in this clinic are better trained or
feel more confident in their ability to help the women in
their care.
DISCUSSION
This study examined satisfaction with care in women
attending Zambian Antenatal clinics. The majority of the
women reported that they were satisfied with care with
98% agreeing that the clinic was helpful. The physical
aspects of the clinic were considered to be satisfactory,
55% of women reported being able to find a seat and
43% reported that the toilet facilities were satisfactory.
Ninety nine percent agreed that they would come for
future appointments. The mean time that the women
reported waiting was 3.6 hours with a range of 1 to 6
hours. Despite the lengthy waiting time women appeared
to committed to clinic attendance. Of the 119 women
with children, only 4 (3.4%) had not attended in their
previous pregnancy. These findings were encouraging
as some of the previous studies (e,g, Ndyomugyenyi et
al.,1998) carried out in Uganda observed that antenatal
care attendance was irregular and few women knew that
the purpose of attending antenatal care was to monitor
both the growth of the baby and the health status of the
woman.
Ndyomugyenyi et al. (1998) reported that health
seeking behaviour was influenced by several factors,
including the perceived high cost of antenatal care
services, of conducting a delivery and treatment, and
perceived inadequacy of services provided by the formal
health system. Inadequacy of formal health services was
perceived by users to be partly due to understaffing and
to irregular supply of essential drugs. In our study, the
main reason women reported attending antenatal clinic
was to check on their health (42%) though only 14 (7.2%)
considered that they had health problems.
Focus group discussions found that there probably
existed a feeling among the participants that it was the
responsibility of the patient to avoid upsetting nursing
staff and therefore not risking poor care. Inexperienced
mothers were particularly vulnerable and this comment
suggests that the clinic culture encourages the collusion
between nurses and more experienced or confident
women to reinforce feelings of uncertainty in “novices”.
These concerns may reflect a lack of staff moral due to
excessive demands. : This findings may be in line with a
UK study by Cliff and Deery (1997) where majority of
women felt that antenatal classes were too technical and
did not address emotional and psychological issues.
Interesting the suggestion made was that male nurses
might be more caring was received with much support by
other members of the focus group perhaps illustrating
how disillusioned the patients felt about the relationship
with the clinic staff.
Women also seemed anxious to follow the advice that
they were given but where information was unclear or
Menon et al.
absent they were not willing to seek clarification. This
may be explained by the findings of an Australian study
that age, education, and socio-demographic variables
therefore appear to play a significant role in antenatal
clinic attendance (Lumley and Brown 1993).
CONCLUSION
The results of the study suggest that although women are
positive about benefits of clinic attendance many feel
intimidated by the process and this may impair
communication and threaten the quality of care that they
receive. Women may be reluctant to disclose
dissatisfaction with care in structured surveys. Both the
focus groups and the survey revealed that women did not
like the physical environment of the clinic. Crowding and
pressure of work in some clinic may cause stress to staff,
which in turn means that they are less sensitive to the
needs of their patients.
In the focus groups
embarrassment and fear were found to inhibit
communication with health practitioners.
RECOMMENDATIONS
It is important for health professionals to ask pregnant
women about their feelings related to the current
pregnancy, childbirth, and future motherhood, and to give
women who express fears an opportunity to discuss
them, paying special attention to primiparas and to
multiparas with negative experiences of earlier
pregnancies (Melender, 2002). The inclusion of women's
voices in the objectives of safe motherhood programmes
is necessary to better serve women's needs (GrossmannKendall et al., 2001). The family perspective implies
knowing both the pregnant woman and her partner in
terms of the pregnancy, the birth and a new parenthood.
Humane, scientifically based perinatal care can be
developed by innovations from these findings, especially
considering the multidimensional role of the parent
groups (Bondas, 2002). Culturally specific changes
needed in the content and mode of antenatal education.
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